<?xml version="1.0" encoding="UTF-8"?>
<!--
To change this template, choose Tools | Templates
and open the template in the editor.
-->
<!DOCTYPE html>
<html xmlns="http://www.w3.org/1999/xhtml" xmlns:ui="http://java.sun.com/jsf/facelets" 
      xmlns:html="http://java.sun.com/jsf/html"
      xmlns:p="http://primefaces.org/ui"
      xmlns:c="http://xmlns.jcp.org/jsp/jstl/core">
    <head>
        <title>TODO supply a title</title>
    </head>
    <body>
        <ui:composition template="/guest/templates/formTemplate.xhtml">
                  <ui:define name="tab">
              <nav>
                    
                    <ul class="menu">
                        <li><a href="Redirect?page=index">Home Page</a></li>
                        <li><a href="Redirect?page=newsList">Our News</a></li>
                         <c:if test="${sessionScope.user == null}">
                        <li><a class="active" href="Redirect?page=guestMenu">Our Employees</a></li>
                        </c:if>
                         <c:if test="${sessionScope.user != null}">
                        <li><a class="active" href="Redirect?page=employeeMenu">Our Employees</a></li>
                        </c:if>
                      <li><a href="Redirect?page=insuranceList">Our Insurances</a></li>
                      <li class="last-item"><a href="Redirect?page=contact">Contact Us</a></li>
                    </ul>
                </nav>
             </ui:define>
            <ui:define name="content">
                <div class="wrapper margin-bot">
                    <div class="col-3">
                      <div class="indent">
                        <h2 class="px">Insurance Details</h2>
                        <form id="From" action="claimInsu" method="post">
                            <table class="tbl1">
                      
                                  <input type="hidden" name="ssuser" value="${sessionScope.user}"/>                                                    
                                <tr>
                                    <td>Claim Reason </td>
                                    <td><textArea style="resize: non" name="txtreason" class="validate[required,maxSize[200]] text-input"/></td>
                                </tr>
                                <tr>
                                    <td>Attachment </td>
                                    <td><input type="file" name="attachment" class="validate[required] text-input" /></td>
                                </tr>
                                <tr>
                                    <td>Amount </td>
                                    <td><input type="text" name="txtamount" class="validate[required,custom[number],min[0],max[200000]] text-input"/></td>
                                </tr>
                            </table>
                            <h2 class="px">Treatment Details</h2>
                            <table class="tbl1">
                                <tr>
                                    <td>Hospital Name </td>
                                    <td><input type="text" name="txthospitalName" class="validate[required,maxSize[20]] text-input"/></td>
                                </tr>
                                <tr>
                                    <td>Hospital Address </td>
                                     <td><textArea style="resize: non" name="txthospitaladdress" class="validate[required,maxSize[30]] text-input"/></td>
                                </tr>
                                <tr>
                                    <td>Hospital Phone </td>
                                    <td><input type="tel" name="txthospitalPhone" class="validate[required,custom[number],minSize[9],maxSize[12]] text-input"/></td>
                                </tr>
                                <tr>
                                    <td>Hospital Fax </td>
                                    <td><input type="text" name="txthospitalFax" class="validate[required,custom[number],minSize[9],maxSize[12]] text-input"/></td>
                                </tr>
                                <tr>
                                    <td>Hospital Email </td>
                                    <td><input type="text" name="txthospitalEmail" class="validate[required,custom[email]] text-input"/></td>
                                </tr>
                                <tr>
                                    <td></td>
                                    <td><div class="buttons"><input class="button-2" type="reset" value="Clear"/><input class="button-2" type="submit" value="Submit" name="action"/></div></td>
                                </tr>
                            </table>
                          </form>
                      </div>
                    </div>
                    <div class="col-4">
                      <div class="block-news">
                        <h3 class="color-4 indent-bot2">Regulations </h3>
                        <dl class="contact p3">
                          <dt><span>Policy Number :</span>14 numbers</dt>
                          <dd><span>Attachment: </span>Pdf files only</dd>
                          <dd><span>Amount:</span>Less than $3000</dd>
                          <dd><span>Hospital Phone :</span>+XXX (XX) XXX-XXXX</dd>
                          <dd><span>Hospital Fax:</span>+X (XXX) XXX-XXXX</dd>
                          <dd><span>Hospital Email:</span>username@domain.com</dd>
                          <dd><span><b>Notice</b></span><text style="color: red">All fields are required!</text></dd>
                        </dl>
                        <p class="text-1"></p>
                      </div>
                    </div>
                  </div>
                  <ui:insert name="box">
                    <ui:include src="/guest/templates/boxTemplate.xhtml"/>
                </ui:insert>
            </ui:define>
        </ui:composition>
    </body>
</html>
